Assignment: Benchmark – Academic Clinical Discharge Summary Note

Assignment: Benchmark – Academic Clinical Discharge Summary Note

Assignment: Benchmark – Academic Clinical Discharge Summary Note

Academic clinical discharge summary notes provide a unique opportunity to practice and demonstrate advanced practice documentation skills, develop and demonstrate critical thinking and clinical reasoning skills, and practice identifying acute and chronic problems and formulating an evidence-based plans of care.

This assignment uses a template. Refer to the “AGACNP Discharge Summary Template,” located on the college page of the Student Success Center under the AGACNP tab.

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Develop an academic clinical discharge summary note based on a hospital patient seen during clinical/practicum. The discharge summary note should include the following:

Reason for admission: Include the reason for admission, a list of diagnoses in order of acuity, and an ICD-10 diagnosis.

List of all procedures: Include all dates, significant findings, and any anesthetics and contrast used during procedures.

Complete list of consults during hospitalization: Include any providers or services consulted during the stay.

Patient’s condition at discharge: Include a physical exam prior to discharge that documents that patient is stable at discharge and has safe disposition and transportation. What diagnostic criteria confirmed the discharge diagnosis?

Complete list of discharge medications: Full list with all dosages, frequencies, and quantity of medications prescribed or dispensed.

Pending test results for follow up: Complete list of any pathology, cultures, radiology, or other diagnostic tests still pending, and who is responsible for follow-up on the final results.

Complete list of discharge instructions: Full list of directions regarding infection prevention, new medications, and returning to daily activities.

Complete list of discharge follow-ups: Full list of any therapies, treatments, referrals, consults, and follow-up appointments. What diagnostic criteria were needed after discharge?

Summary: What questions were raised during the hospital stay? Include all explanations and answers to these questions. What questions were raised that required further exploration? What kind of discharge planning did you need? Characterize your patient interaction activities.

Overall assessment: Identify health promotions, health education, ethical considerations, geriatric considerations, and expected outcomes.

Incorporate three peer-reviewed articles in the assessment or plan.

While APA style is not required for the body of this assignment, solid academic writing is expected, and documentation of sources should be presented using APA formatting guidelines, which can be found in the APA Style Guide, located in the Student Success Center.

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.

You are required to submit this assignment to LopesWrite. A link to the LopesWrite Technical Support Articles is located in Class Resources if you need assistance.

Benchmark – Academic Clinical Discharge Summary Note – Rubric

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Reason for Admission and Full Diagnosis (B) 4 points

Criteria Description

Reason for Admission and Full Diagnosis (C 7.1)

5. Target 4 points

A description of the reason for admission, a list of diagnoses in order of acuity, and an ICD-10 diagnosis are thorough and include substantial supporting details.

4. Acceptable 3.6 points

A description of the reason for admission, a list of diagnoses in order of acuity, and an ICD-10 diagnosis are present and include supporting details.

3. Approaching 3.2 points

A description of the reason for admission, a list of diagnoses in order of acuity, and an ICD-10 diagnosis are present.

2. Insufficient 2 points

A description of the reason for admission, a list of diagnoses in order of acuity, and an ICD-10 diagnosis are incomplete or incorrect.

1. Unsatisfactory 0 points

A description of the reason for admission, a list of diagnoses in order of acuity, and

List of All Procedures                                                                                                                                      4 points

Criteria Description List of All Procedures

5. Target 4 points

A list of all dates, significant findings, anesthetics, and contrast used during procedures is complete.

4. Acceptable 3.6 points

N/A

3. Approaching 3.2 points

N/A

2. Insufficient 2 points

A list of all dates, significant findings, anesthetics, and contrast used during procedures is incomplete.

Consults During Hospitalization 4 points

Criteria Description

Consults During Hospitalization

5. Target 4 points

A complete list of consults during hospitalization, including any providers or services consulted during the stay is complete.

4. Acceptable 3.6 points

N/A

3. Approaching 3.2 points

N/A

2. Insufficient 2 points

A list of consults during hospitalization, including any providers or services consulted during the stay, is incomplete.

1. Unsatisfactory 0 points

Condition of Patient at Discharge 4 points

Criteria Description

Condition of Patient at Discharge

5. Target 4 points

Documentation of a physical exam prior to patient discharge that notes the safety and stability of the patient, in addition to any diagnostic criteria that confirmed the discharge diagnosis, is thorough and includes substantial supporting details.

4. Acceptable 3.6 points

Documentation of a physical exam prior to patient discharge that notes the safety and stability of the patient, in addition to any diagnostic criteria that confirmed the discharge diagnosis, is present and includes supporting details.

3. Approaching 3.2 points

Documentation of a physical exam prior to patient discharge that notes the safety and stability of the patient, in addition to any diagnostic criteria that confirmed the discharge diagnosis, is present.

2. Insufficient 2 points

Documentation of a physical exam prior to patient discharge that notes the safety and stability of the patient, in addition to any diagnostic criteria that confirmed the

Discharge Medications                                                                                                                                      4 points

Criteria Description Discharge Medications

5. Target 4 points

A full list of discharge medications that includes all dosages, frequencies, and quantities of medications prescribed or dispensed is complete.

4. Acceptable 3.6 points

N/A

3. Approaching 3.2 points

N/A

2. Insufficient 2 points

A list of discharge medications that includes all dosages, frequencies, and quantities of medications prescribed or dispensed is incomplete.

1. Unsatisfactory 0 points

Pending Test Results for Follow-Up 4 points

Criteria Description

Pending Test Results for Follow-Up

5. Target 4 points

A complete list of any pathology, cultures, radiology, or other diagnostic tests still pending, including an indication of who is responsible for follow-up on final results, is complete.

4. Acceptable 3.6 points

N/A

3. Approaching 3.2 points

N/A

2. Insufficient 2 points

A complete list of any pathology, cultures, radiology, or other diagnostic tests still pending, including an indication of who is responsible for follow-up on final results, is incomplete.

1. Unsatisfactory 0 points

A complete list of any pathology, cultures, radiology, or other diagnostic tests still

Discharge Instructions                                                                                                                                      4 points

Criteria Description Discharge Instructions

5. Target 4 points

Directions regarding infection prevention, new medications, and returning to daily activities are thorough and include substantial supporting details.

4. Acceptable 3.6 points

N/ADirections regarding infection prevention, new medications, and returning to daily activities are present and include supporting details.

3. Approaching 3.2 points

Directions regarding infection prevention, new medications, and returning to daily activities are present.

2. Insufficient 2 points

Directions regarding infection prevention, new medications, and returning to daily activities are incomplete or incorrect.

Discharge Follow-Ups (B)                                                                                                                                      4 points

Criteria Description Discharge Follow-Ups (C.7.3)

5. Target 4 points

Therapies, treatments, referrals, consults, and follow-up appointments, in addition to any diagnostic criteria needed after discharge, are thorough and include substantial supporting details.

4. Acceptable 3.6 points

Therapies, treatments, referrals, consults, and follow-up appointments, in addition to any diagnostic criteria needed after discharge, are present and include supporting details.

3. Approaching 3.2 points

Therapies, treatments, referrals, consults, and follow-up appointments, in addition to any diagnostic criteria needed after discharge, are present.

2. Insufficient 2 points

Therapies, treatments, referrals, consults, and follow-up appointments, in addition to any diagnostic criteria needed after discharge, are incomplete or incorrect.

1. Unsatisfactory 0 points

Therapies, treatments, referrals, consults, and follow-up appointments, in addition

Summary                                                                                                                                      4 points

Criteria Description

Summary

5. Target 4 points

The addressing of questions raised during the hospital stay, in addition to a discussion about questions requiring further exploration, discharge planning, and patient interaction activities, is thorough and includes substantial supporting details.

4. Acceptable 3.6 points

The addressing of questions raised during the hospital stay, in addition to a discussion about questions requiring further exploration, discharge planning, and patient interaction activities, is present and includes supporting details.

3. Approaching 3.2 points

The addressing of questions raised during the hospital stay, in addition to a discussion about questions requiring further exploration, discharge planning, and patient interaction activities, is present.

2. Insufficient 2 points

The addressing of questions raised during the hospital stay, in addition to a discussion about questions requiring further exploration, discharge planning, and

Overall Assessment                                                                                                                                      4 points

Criteria Description Overall Assessment

5. Target 4 points

Identification of health promotions, health education, ethical considerations, geriatric considerations, and expected outcomes is thorough and includes substantial supporting details.

4. Acceptable 3.6 points

Identification of health promotions, health education, ethical considerations, geriatric considerations, and expected outcomes is present and includes supporting details.

3. Approaching 3.2 points

Identification of health promotions, health education, ethical considerations, geriatric considerations, and expected outcomes is present.

2. Insufficient 2 points

Identification of health promotions, health education, ethical considerations, geriatric considerations, and expected outcomes is incomplete or incorrect.

1. Unsatisfactory 0 points

Mechanics of Writing                                                                                                                                      5 points

Criteria Description

Includes spelling, capitalization, punctuation, grammar, language use, sentence structure, etc.

5. Target 5 points

No mechanical errors are present. Skilled control of language choice and sentence structure are used throughout.

4. Acceptable 4.5

Few mechanical errors are present. Suitable language choice and sentence structure are used.

3. Approaching 4 points

Occasional mechanical errors are present. Language choice is generally appropriate. Varied sentence structure is attempted.

2. Insufficient 2.5 points

Frequent and repetitive mechanical errors are present. Inconsistencies in language choice or sentence structure are recurrent.

Format/Documentation                                                                                                                                      5 points

Criteria Description

Uses appropriate style, such as APA, MLA, etc., for college, subject, and level; documents sources using citations, footnotes, references, bibliography, etc., appropriate to assignment and discipline.

5. Target 5 points